Magazine article Clinical Psychiatry News

Agitation, Aggression Demand Clinical Acumen: Practical Psychopharmacology; What Experts Do before Study Results Are in. (Pshychopharmacology)

Magazine article Clinical Psychiatry News

Agitation, Aggression Demand Clinical Acumen: Practical Psychopharmacology; What Experts Do before Study Results Are in. (Pshychopharmacology)

Article excerpt

Although agitation and aggression are frequent problems in elderly patients with dementia, pharmacotherapy isn't always the solution.

"The first question is, 'What's the diagnosis?'" said Dr. Ira R. Katz, director of the geriatric psychiatry section at the University of Pennsylvania, Philadelphia.

Given the possibility of delirium, such medical causes as pneumonia and urinary tract infections must be identified and addressed, he said.

Pain of diverse origin may be responsible, noted Dr. Jacobo E. Mintzer, director of geriatric psychiatry at the Medical University of South Carolina, Charleston. One study of agitated wheelchair-bound patients found several undiagnosed hip fracture cases, for example.

More broadly, agitation may reflect a frustrated attempt to express needs that, because of cognitive deficits, the patient cannot otherwise communicate.

"When specific needs are satisfied, the symptom disappears," Dr. Mintzer pointed out.

If possible, behavioral problems should be resolved with behavioral interventions. "The brain is the organ of adaptation, and dementia eeps patients from adapting to their environment."

A useful response is "adjusting the environment to fit what the patient can tolerate," Dr. Katz said.

"In some cases, over-stimulation leads to agitation; in others, understimulation [triggers agitation]," he said.

Simplifying the environment, increasing the number of interpersonal interactions, or scheduling activities to fill the time can be helpful.

The point when medication is called for, either alone or in combination with psychosocial approaches, may depend on the setting, said Dr. Nathan Herrmann, head of the division of geriatric psychiatry at the University of Toronto. In the home, "it's sometimes very difficult for caregivers to institute strict behavioral measures; they don't have the emotional or financial resources."

Similarly, in long-term-care facilities, limited patient contact may mae non-pharmacologic interventions impracticable, he said.

Symptom severity is another factor.

"We may prefer to start with behavioral approaches, but given the degree of suffering that the patient and caregiver are undergoing, we sometimes need to hit on all cylinders," Dr. Herrmann said.

Safety--of the patient and of those providing care--also can argue for medication.

In choosing drugs, diagnosis again comes to the fore: When agitation or aggression occurs in the context of a clearly identifiable psychiatric syndrome--such as psychosis or depression--the underlying condition should be addressed, he said.

But with no apparent diagnosis beyond dementia, "there are a number of medications on the table," Dr. Katz said.

"The ones with best-established efficacy are the antipsychotics.

"If agitation or aggression is sufficiently intense [to warrant medication], the way to put out the fire is with an atypical."

Dr. Herrmann agreed that their efficacy and tolerability mae atypical antipsychotics the first-line drug choice, even if agitation is relatively mild. "We shouldn't withhold potentially helpful treatments because of fears based on older medications," he said.

For both Dr. Katz and Dr. Herrmann, the choice essentially comes down to the atypical antipsychotics that have been baced by controlled research in this application: risperidone and olanzapine. …

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